Palliative care + pain management Flashcards
Cerebral tumour - mx
- Urgent neurosurgical opinion to make a definitive dx and continue tx
- Exact nature of SOL on CT not known at this stage so should be positive in approach (without being misleading), but be firm about the need for referral
- Indicate that more tests (e.g. MRI) may be ordered by neurosurgeon and that surgery may be required
- Make consultant appointment whilst pt is with you for as soon as possible
- Fax referral and ask family members to go with him
- Supportive treatment if other symptoms, e.g. for recurrent headache - paracetamol + codeine, but in consultation with neurosurgeon. Corticosteroids may be treatment of choice
- Offer to F/U/review after pt has seen neurosurgeon. State that you will confer with the specialist. Give them permission to contact you any time, about any concerns
Cerebral tumour - prevention
- Warn pt to return immediately if sx such as vomiting, weakness or drowsiness occur
- Request pt to cease alcohol, at least on a temporary basis
- Consider advice on smoking cessation at the right opportunity
- Suggest that pt does not drive until neurosurgery review. If family members can’t take them, organise transport
Unexpected death - mx
- Express sympathy
- Explain and respond to questions about the cause of loved one’s death
- Respond to pt’s feelings of guilt and responsibility for death - don’t take any perceived anger personally
- Explain that often people feel responsible after a sudden and unexpected death - i.e. normalise the response
- Ask how the pt is coping
- Ask what support they have - i.e. family, friends, clubs, church. ‘Who is there for you at the moment?’
- Do they need extra help? Emphasise the importance of trying to continue normal routines
- Make another appointment in a couple of weeks
Unexpected death - prevention
- Give anticipatory advice
- Ensure patient reports if not coping
- Reinforce normality of grieving process
Terminal cancer - initial phases of interview
1/2/3. Establish what the patient has been told in hospital and their level of understanding and attitude towards the dx.
a. Determine if the pt is seeking the ‘blunt facts’ or is wanting reassurance about the dx
b. Determine whether the pt wishes to discuss prognosis
c. Be as honest as possible, in a caring, empathetic way
- Educate pt about dx (but allow plenty of opportunity for them to ask questions)
a. Original growth has now spread -> causing … sx
b. Temporary treatment - allowing body to function normally for the time being
c. Not all the tumour could be removed
d. Reassurance that despite some tumour being left in situ, quality of life and ADLs may remain normal for some time
e. Avoid quantifying dx
Terminal cancer - mx
a. Immediate
1. Ensure pain control. If visceral pain, do not prescribe NSAID/paracetamol + codeine, but go straight to low dose oral opioid, e.g. MS Contin (morphine) or Oxycontin (oxycodone) 5-10mg BD. Warn of risk of constipation and prescribe a laxative (e.g. coloxyl with senna 1 BD). Emphasise that dose of laxative should be increased if pt does not open their bowels at least once every 3d.
2. Discuss referral to oncologist, in particular for opinion about chemotherapy which is likely to be offered. Reinforce that pt’s management will include the surgeon, oncologist and you, and that the specialists will be ringing and writing to you (GP)
3. Suggest a good diet, small meals often
4. Say that you will be arranging a referral to the local domiciliary palliative care service. They will be keeping an eye on regular pain, bowels, emotional problems and coping. Check if there is additional support that will be of help, e.g. home help, meals on wheels, respite care for partner
5. Discuss how partner and family are coping. Arrange round-table family meeting
6. Discuss need for company and for pt to be treated normally
7. Reassure that you will be available, but that if you are not working, who will be covering you and how they can be contacted
8. F/U initially weekly and then as the need arises
b. Long-term
1. Detailed long-term mx plans can be left to a later interview
2. Advisable to indicate to pt that at some stage, it would be beneficial to consider discussing issues such as long-term care of partner. Views on institutional care vs. home care, etc. Ideally, the objective should to be to manage all problems at home
3. If pt specifically asks, reassure them that there is much that can be done to relieve cancer pain, and that very few pts do not have their pain satisfactorily managed. State that most pts achieve good pain control with oral medications. Sometimes a subcutaneous syringe driver is needed for pain killers and anti-emetics, and can usually be managed at home. If pain/other sx are a problem at home, the domiciliary palliative care nurse or GP may arrange a referral to a palliative medicine specialist or a short inpatient hospice admission
Terminal cancer - prevention
- Anticipate problems, especially pain, and organise analgesia around the clock
- Proactive mx of bowel function
- Reinforce your availability and care at all times
